August 8, 2002
UNPROTECTED PEOPLE: Stories of
people who have suffered or died from vaccine-preventable diseases
"TETANUS--PUERTO RICO, 2002"
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August 8, 2002
UNPROTECTED PEOPLE #48: "TETANUS--PUERTO RICO, 2002"
The Immunization Action Coalition (IAC) publishes stories of people who have
suffered or died from vaccine-preventable diseases and occasionally devotes
an IAC EXPRESS issue to such a story. This is the 48th story in our series.
"Tetanus--Puerto Rico, 2002" was first published by the Centers for Disease
Control and Prevention (CDC) in the July 19, 2002, issue of Morbidity and
Mortality Weekly Report (MMWR; vol. 51, no. 28). The article discusses three
cases of tetanus (two fatal) in men over 60 years of age, serving as a
reminder that "adults aged 60 years or greater are at greatest risk for
tetanus and tetanus-related mortality." Because almost all
tetanus-associated deaths are preventable through adequate vaccination,
health-care providers should make sure all patients, including older
patients, receive a tetanus booster if they haven't had one in the past ten
years. Note: For both routine boosters and managing the wounds of adults, Td
(tetanus and diphtheria toxoids) is preferred over TT (tetanus toxoid) alone
to enhance protection against diphtheria, to which many adults are also
During February-May 2002, the Puerto Rico Department of Health (PRDOH)
received reports of three tetanus cases, two of which were fatal. The last
reported case of tetanus in Puerto Rico had occurred in 1999. This report
summarizes the investigations of these three cases, which underscore that
health-care providers should ensure that all patients have been vaccinated
fully against tetanus (1,2).
Case 1. On December 19, 2001, a man aged 86 years with a history of
hypertension and coronary artery disease (CAD) sustained a splinter in his
right hand while gardening. On December 22, the patient saw a physician for
wound care. At that time, he was not treated with either a tetanus toxoid
vaccine or prophylactic tetanus immune globulin (TIG). His tetanus
vaccination history was not documented in the medical record; he had no
history of military service.
On December 26, the patient received treatment for pharyngitis from a local
physician. On December 29, he presented to an emergency department (ED) with
difficulty talking, swallowing, and breathing and with chest pain and
disorientation of 2 days' duration. He was admitted to a general medicine
ward with a preliminary diagnosis of stroke.
On January 2, 2002, the patient had neck rigidity and respiratory failure
requiring tracheotomy and mechanical ventilation and was transferred to the
intensive care unit (ICU) with tetanus diagnosed. He was administered a dose
of tetanus and diphtheria toxoids (Td); TIG was ordered but was unavailable.
On January 11, the patient received nonspecific intravenous immune globulin
(pooled plasma, 7.5 grams). His hospital course was complicated by two
myocardial infarctions, congestive heart failure, a lacunar stroke, and
pneumonia. He died on February 2.
Case 2. On April 18, 2002, a man aged 68 years with a history of
diabetes mellitus, CAD, and mitral valve replacement sustained a puncture
wound in his right foot from stepping on a rusted nail. His spouse cleaned
the wound with a surface antiseptic (benzalkonium chloride). The following
day, the patient sought care from a primary-care physician who administered
intravenous cefazolin and prescribed oral ciprofloxacin and oxycodone. The
patient requested vaccination against tetanus but was told that the vaccine
was unavailable. The patient did not know if he had been vaccinated
previously against tetanus; he had not served in the military.
On April 22, the patient presented to an ED complaining of difficulty
swallowing, mild shortness of breath, abdominal pain, throat pain, and
mandibular rigidity. On physical examination, he had trismus, risus
sardonicus, muscular rigidity, and difficulty speaking. He was admitted to
the ICU with diagnoses of suspected tetanus and right foot cellulitis. He
was treated with metronidazole, ciprofloxacin, and midazolam by continuous
intravenous infusion. On April 23, the patient had seizures and respiratory
failure requiring mechanical ventilation. He also was given intramuscular
TIG (500 units) and Td (0.5 cc) at that time. Despite midazolam therapy and
supplemental diazepam for seizures, the patient's muscle spasms persisted.
He died on April 27.
Case 3. On April 10, 2002, a man aged 76 years with a history of
hypertension sustained a splinter in his right hand. On April 18, the
patient experienced weakness and dysphagia, and on the following day,
trismus. At that time, he was treated for otitis media but refused Td
vaccination. His previous tetanus vaccination status was unknown; he had not
served in the military.
On April 20, the patient presented to an ED with difficulty walking,
talking, and swallowing. He did not report any wound history to the
attending physician. He was treated with an intramuscular corticosteroid
injection and an antihistamine. On April 21, the patient sought care at
another ED. He was admitted to the ICU with diagnosed tetanus and intubated
preemptively. On April 22, he received 3,000 units of TIG and was started on
metronidazole. His course was complicated by methicillin-sensitive
Staphylococcus aureus pneumonia and pseudomembranous colitis. He was
released from the hospital on June 17.
During January 1990-April 2002, PRDOH received reports of 20 cases of
tetanus (average annual incidence rate: 0.04 per 100,000 population). Of
these, 18 (90%) were in men; the median age was 70 years (range: 55-86
years). Among the 11 (55%) for whom supplemental information was available,
none had a definite history of previous vaccination with tetanus toxoid.
Five (25%) patients had a history of diabetes mellitus. The overall
case-fatality rate was 68%.
As a result of the Td shortage affecting the United States during 2000-2002,
PRDOH instituted a protocol in March 2001 consistent with the modified
guidelines for Td use during the shortage (3,4). Priority was given to
persons requiring prophylaxis for wound management and to persons who had
previously received fewer than 3 doses of tetanus-containing vaccine, and
routine Td boosters in adolescents and adults were deferred. The shortage
reduced Td use in Puerto Rico by 67% during 2000-2001 (Puerto Rico
Immunization Program, unpublished data, 2002).
In response to the recent tetanus cases, PRDOH has 1) continued reminding
health-care providers of the increased risk for tetanus among persons aged
60 years or greater and those with no history of primary vaccination against
tetanus; 2) promoted an increase in the availability of TIG for prophylactic
and therapeutic use; and 3) notified physicians that the Td shortage has
ended and that Td is available for routine indications (5).
Reported by: JC Orengo, MD, Y Garcia, MPH, A Rodriguez, MD, J Rullan, MD,
Puerto Rico Dept of Health. MH Roper, MD, P Srivastava, MS, TV Murphy, MD,
Epidemiology and Surveillance Div, National Immunization Program; F
Alvarado-Ramy, MD, Div of Applied Public Health Training, Epidemiology
Program Office, CDC.
Tetanus is a rare disease in the United States; following the introduction
of vaccination with tetanus toxoid in the 1940s, the overall incidence of
tetanus declined from 0.4 per 100,000 population in 1947 to 0.02 during the
latter half of the 1990s. The overall case-fatality ratio declined from 91%
to 11% during the same period. The majority of tetanus cases reported during
1989-1997 occurred in persons who had not completed a 3-dose primary tetanus
toxoid vaccination series or for whom vaccination histories were uncertain;
no tetanus deaths occurred in persons who received primary tetanus
vaccination (5-7; CDC, unpublished data, 2002).
Adults aged 60 years or greater are at greatest risk for tetanus and
tetanus-related mortality (5-7). During 1998-2000, the average annual
incidence of tetanus in persons aged 60 years or greater was 0.03 with a
case-fatality ratio of 31%, both more than twice that of adults aged <60
years. The increased risk for tetanus with increasing age is thought to be
related to the lower prevalence of protective immunity in older age groups.
Protective levels of antibodies against tetanus toxoid decline with age; by
age 70 years, only 30% of the population is protected (8). Older persons
might never have received a primary vaccination series or might not have
received subsequent Td boosters. Women are significantly less likely to be
protected against tetanus than men (8) probably, in part, because women are
less likely to have received a Td booster in conjunction with military
The Td shortage during 2000-2002 necessitated deferral of routine Td
boosters in adolescents and adults. However, booster doses given as part of
wound management and administration of primary series in unvaccinated
persons remained priorities (3). Previous reports on tetanus cases occurring
in the United States during the 1980s and 1990s indicated that even during
periods in which Td was in ample supply, <60% of persons for whom Td was
indicated received a dose during wound management (5-7).
Recommendations for the use of Td and TIG for wound care depend on the
nature of the wound and the patient's vaccination history. Persons who have
received a primary tetanus vaccination series but who have not had a Td
booster during the 10 years preceding any injury should receive a booster
dose. Persons who present with wounds contaminated with dirt, feces, or
saliva, deep wounds, or wounds with necrotic tissue and who have not had a
booster during the preceding 5 years also should receive a dose of Td.
Persons who have never received tetanus vaccination or those with unknown or
uncertain vaccination histories should receive the first dose of a primary
series at the time of presentation. These patients also should receive TIG
(250 units injected intramuscularly at a site distant from that used for Td
administration) unless the wound is superficial and clean, because a single
dose of Td in the absence of previous tetanus vaccination will not induce
the production of protective levels of antibody. Therapeutic TIG
(3,000-6,000 units as 1 dose) should be administered as soon as possible to
any patient presenting with tetanus (9).
The majority of cases of tetanus and virtually all tetanus-associated deaths
are preventable through adequate vaccination. Because all wounds, even minor
and relatively clean wounds, confer a risk for tetanus, health-care
providers should review the vaccination status of all patients and
administer indicated tetanus toxoid vaccine to keep their patients fully
- CDC. Diphtheria, tetanus, and pertussis:
recommendations for vaccine use and other preventive
measures--recommendations of the Immunization Practices Advisory Committee
(ACIP). MMWR 1991;40(No.RR-10).
- CDC. Immunization of adolescents:
recommendations of the Advisory Committee on Immunization Practices, the
American Academy of Pediatrics, the American Academy of Family Physicians,
and the American Medical Association. MMWR 1996;45(No. RR-13).
- CDC. Shortage of tetanus and diphtheria
toxoids. MMWR 2000;49:1029-30.
- CDC. Deferral of routine booster doses of
tetanus and diphtheria toxoids for adolescents and adults. MMWR
- CDC. Resumption of routine schedule for
tetanus and diphtheria toxoids. MMWR 2002;51:529-30.
- Prevots R, Sutter RW, Strebel PM, Cochi
SL, Hadler S. Tetanus surveillance--United States, 1989-1990. In: CDC
Surveillance Summaries (December 11). MMWR 1992;41 (No. SS-8).
- Izurieta HS, Sutter RW, Strebel PM, et al.
Tetanus surveillance--United States, 1991-1994. In: CDC Surveillance
Summaries (February 21). MMWR 1997;46 (No. SS-2).
- Bardenheier B, Prevots R, Khetsuriani N,
Wharton M. Tetanus surveillance--United States, 1995-1997. In: CDC
Surveillance Summaries (July 3). MMWR 1998;47(No. SS-2).
- McQuillan G, Kruszon-Moran D, Deforrest A,
Chu SY, Wharton M. Serologic immunity to diphtheria and tetanus in the
United States. Ann Int Med 2002;136:660-6.
- American Academy of Pediatrics. Tetanus.
In: Pickering LK, ed. 2000 Red book: report of the Committee on Infectious
Diseases. 25th ed. Elk Grove Village, Illinois: American Academy of
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